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Good morning and thank you for joining us. This is Matthew Byrne your host. Navigating Health Insurance, that is our topic, that is our blog, thank you for joining us. Please bookmark this show and join us frequently. We will be doing weekly episodes so we hope that you will come back and be a regular participant in our online Blog Talk Radio community. Today, we are gonna talk about nomenclature, terminology, words and things that you need to know and be comfortable with. You are gonna become a health insurance shopping expert and have a -- maybe a guest and certainly our calling people so we look forward to having people call in. If you need to call in you can call (818) 668-5442. If you are listening to this as the recorded version, obviously the call-in number is not available but if you are catching us live, definitely feel free to call in and we will filled your call on the fly. That is (818) 668-5442. So, you know a lot of times -- just a little background about us and me and why I have come today. I think that -- I kind of have a personal vendetta against the health insurance industry. I do not think that they properly educate or clear in their communications and how they articulate their health insurance plan design. So I kind of have a personal mission to demystify some of those terms and some of those definitions and I just wanna provide a working vocabulary for anyone who is kind of in the market shopping for insurance whether it would be Group Health, you know employee benefit programs or individual and family coverage. I kind of understand in the basics of what they call these things is kind of a critical element so -- they get started on that. One of the big things is that you got copays and co-insurance, okay? So a copay is first dollar coverage on any service with some sort of small co-payments such as -- we are all pretty familiar with this one.
This is one of the definitions that is probably least intimidating, but let us say you have a $15 generic prescription copayment. That would get you a 30-day supply of a generic medicine for $15. Obviously, the cost of that medicine maybe significantly higher than $15, but your share is $15 that is a copayment, in insurance companies, copaying the rest, okay? Another copayment would be in a form of office visits. A lot of times you see a $30 copayment for a normal doctor's office visit, maybe $40 for specialist visit. Okay, that is again first dollar coverage which means you do not have to meet your deductible. You get that -- day one dollar one, you pay a $30 copayment and it will pay you for the doctor's office services and again, it is a copayment because your $30 is probably does not cover the entire cost of the doctor's office visit. The insurance company -- co-shares or copays that is with you. So, for example, if the doctor has a $150 fee for his service maybe then the health insurance company negotiates that down to $60 or $70 part of their contract negotiations. You pay $30 copay. The insurance company will pick up the $40 balance so that is the copayment. The next one is the deductible. The deductible is the amount that you pay for insurance before the real -- large part of your benefit kicks in. The deductible is 100% on you. Okay, so if you have $1000 deductible and you got into a car accident and they want to do an x-ray and an MRI and do a casting then you would pay the first thousand dollars, okay?
Co-insurance is once you have met this deductible, once you have pay the 100% of your deductible up to $1000 in our analysis or a scenario, co-insurance is where you might pay 20% an 80/20 co-insurance because you pay 20% of every dollar thereafter and the insurance company paid 80. I called the second deductible okay, very important. Deductible all on you co-insurance, the insurance company pays the 80% and you pay 20%, I called that the second deductible. So if you say, "Alright I have 80/20 plans." That means you have $1000 deductible and then they will pay 80% after that, you will pay 20%, typically up to another $1000 or even $2000, okay? So $1000 are deductible 80/20 plan might have a total out-of-pocket of $3000 because if you out-of-pocket is the amount you totally pay if something major happens. So, if you add deductible plus co-insurance, you equal the out-of-pocket maximum and -- out-of-pocket maximum is the most you would pay in any situation. Okay, so again thank you for calling. If you need to reach us we hope that you would certainly use our call-in number, come back and bookmark this frequently and often and we are talking about terminology, the glossary of terms that you need to know to be a good and savvy insurance shopper. Copayment is the amount that you pay when you go to doctor's office and it really just as confine to that doctor's visit. If you need to do an x-ray or blood test or some sort of MRI or anything of that nature, the copayment is exhausted. You will be subject to your deductible.
Subject to your deductible is a term that gets drawn out a lot. That basically means you are paying for it okay, until you have met your deductible. So, if somebody says "Oh, you know emergency room visits are subject to your deductible or labs and imaging are subject to your deductible or counseling are subject to your deductible." That means that you pay for it at 100% until you satisfied the entirety of your deductible, okay? If it says subject to the deductible and co-insurance, it means you pay for it at a 100% up to your deductible and then you pay - in an 80/20 coinsurance plan, you pay 20% of every dollar thereafter until you satisfied your - what we called the second deductible which is your co-insurance amount. The other thing that you need to know is that when you have - typically when you have a coplay plan or unless it is otherwise pretty obviously stated, your deductible is x2 for the family so for the husband wife, you have two deductibles. If it is a husband and wife and four children, you have two deductibles okay, not six deductibles just two. On a health savings account or some plans - where they have articulated very clearly you may have one deductible so it might be $5,000 for the whole family, no co-insurance okay. So, if you see your plan assets has 0% co-insurance it basically means once you had the deductible you are done. So again, out-of-pocket limit is deductible plus co-insurance equals out-of-pocket limit, alright. Other things you wanna look for when you are shopping for health insurance is your limitations, does my plan have any limits like I can only have a million dollars of claims a year or does it have lifetime limits or only have $5 million worth of claims a year. Health reform has - those types of limits, they are attempting in moving forward or doing a way with those types of things so typically if you buy a new plan, it is gonna have no lifetime or annual limits.
But the plan you may currently have or the one you have through work may have some lifetime limits so look at their lifetime limits and whether or not your plan has one or not. Coverage services, this is another term that I think is kind of - an important thing to understand and to know. If you ask is this service covering you, this is the cover in a maternity, this is cover counseling or drug and alcohol rehabilitation, does my plan cover emergency room visits or urgent care visits. A lot of times, you get the answer yes because most plans cover those types of things. However, whether it is covered or not does not necessarily define who pays for the service, okay? If you are beneath your deductible and it is a coverage service, you will pay for the service. If you are above your deductible and then in co-insurance which we call the second deductible. If you satisfied your maximum out-of-pocket, it is a coverage service and the insurance company will pay for it. So whether or not something is covered is a question that could get you in the trouble so make sure that you are asking is it covered and who is gonna pay for it and I like to do scenarios. Let us say you are going for your mammogram that is a coverage service and preventive on the plan that I am describing to this particular client is 100% paid for. So not only as covered, but it is paid for by the insurance company. Let us say they find the lump and want to do an MRI on that, the MRI is covered subject to deductible which means you pay for it. Once you satisfied, your deductible is $1000 in any co-insurance then the plan would pay the balance. So, let us say we have $1000 deductible plan with $2000 of co-insurance for a maximum out-of-pocket of $3000 and that is - let us just say this is for a single individual. You go in for the mammogram in free. If they find a lump on your armpit, wanna do an MRI that cost $1000.
You would pay the $4000 because that is part of your deductible. Let us say they want to do a CAT scan as well and it is - $2000, you would pay 20% of the $2000 and they would pay 80% so in that case you would pay $400 and the insurance company will pay $1600. Let us say they wanna do chemotherapy and radiation for a total of $100,000. Once you had met the full out-of-pocket maximum of 3 grand, they will pay 100% of everything after that so in that scenario, you will pay the first $1000 all by yourself. You will share the 20% co-insurance for the next $2000 and once you hit $3000, they would pay 100% of everything up to that which would be in this scenario $97,000. Let us do a more modest scenario. Let us say you have $10,000 of an accident for example. So they bring you to the ER, they do some x-rays and put you in traction and that type of thing and the total bill is $10,000 or you pay the first thousand all by yourself okay, and then the balance would be $9000 which you would be then responsible for 20% of up to a maximum of $3000 out-of-pocket. So 20% would be another $1800. So, you will pay the first thousand dollars and then you will pay an $1800 in co-insurance and you will have met $28,000 of your $3000 deductible. So on a plan like that a $10,000 claim does not even get you totally out from underneath - the cost sharing. Now, on a $20,000 claim, you would pay $3000 because at that point you would have maxed out your plan.
So again this is Matt Byrne. Today, we are talking about definitions, glossary, naming conventions in the health insurance industry and things that you need to kind of be aware of and be savvy at. So, as you shop for an individual health insurance plan, you will kind of have the ammunition you need. We have a website that allows you to shop 250 plans from 10 different health insurance companies. It is called MyHealthQuoter.com. Feel free to go and visit that site. We are not licensed and operating in all states, but if you fill out the census form, it will route you to one of our affiliate partners who can be of assistance to you and provide you some quoting, help and guidance and answer any questions that you may have. Please go ahead and bookmark this show. We are gonna be doing a weekly series and trying to provide an insiders guide to some of the different things you might wanna know and things that you will need to kind of be aware of as you shop for your health insurance. We will cover topics like COBRA, accident policies, critical illness and long-term care insurance, life insurance products. We will look at health reform. We are very up-to-date on those. We will kind of give you up-to-date blow by blow on health reform. Some of the things about health reform that you need to know as a new consumer as that all preventive services are included, okay. So if you are gonna go for your mammogram, your Pap smear, your annual physical, your routine cholesterol and blood testing, those things will always be paid for 100% no matter what plan you are on. Assuming your plan is health reform compliance and this is a newer plan, but purchased after September 23, 2010, if you are on a grandfathered plan, those amenities and those new luxuries would not be available for you until you did a plan design change either on an employer level or if you are an individual or family, once you upgrade or change your plan then you would have a health reform compliant plan and no longer a grandfathered plan. So preventive, a lot of times people are a little bit confuse about that.
They say, "Hey, you know I get my cholesterol all read every six months and they did a - they pulled a blood panel for cholesterol last week and I got a bill for the whole test. You know I thought preventive was covered." Well, if you have a condition of cholesterol, a blood panel is on longer a preventive service. That is now a diagnostic monitoring maintenance or treatment related service and would be quoted as such by your physician. So, let me give you another example. Let us say you are going to the doctor for your physical and you say "Hey doc" you know - and the doctor say, "How you're doing, how you're feeling" and you say "Yeah, I'm great just here for a routine physical for preventive everything is great" he is like "Any complaints or concerns" and you say "Well yeah, I haven't been sleeping very well, but other than that yeah, it's great." Now, the blood panel that the doctor pulled is probably gonna be a diagnostic blood panel. He is gonna be looking for different things. He is gonna be studying it with a more keen eye and he is probably gonna code that as a diagnostic related blood panel because you express the complaint about sleeplessness where the - so in that situation you are gonna pay for that blood panel because it is diagnostic. Had you simply said, "Oh doc, yeah I'm feeling fine." He probably had pulled the same blood panel, look at the same various different things and the difference is that he would have quoted that one as preventive. So a good conversation to have with your doctor is, yeah I have free preventive service if we were going to do something that is not preventive can we please have a conversation so that you know I'm gonna be paying for out-of-pocket up to the first thousand dollars. Let us please - let me know that so we can have a conversation about that and make sure that this is the right thing to do for me. So preventive is gonna be free and non-grandfathered plans or what we call health reform compliant plans and anything that is preventive in nature and recommend by the American Medical Association is typically gonna be covered - colonoscopy. If you are 35, it is not gonna be covered, but if you are 65, a colonoscopy probably is covered as long as it is not in result of some sort of stomach cramp or stomach pain.
Or some sort of - if you got a family history and the doctor is kind of doing colonoscopy to the point of exploration or discovery or diagnostic and he is fishing for issues, it might not be quoted as preventive, but if it is just a truly routine, no red flags then it is quoted properly that that should be free to you. So anyway, my name is Matthew Byrne. My company is MyHealthQuoter.com. Tune in frequently and often and we will also archive some of this to a recording so that if you want to check back in and get the latest and greatest - we will be doing 30-minute sessions once a week. We will do that, comeback, bookmark us or just go to Blog Talk Radio and search for Navigating Health Insurance, that is our title and topic. Again, if you would like to call us in the future, we would love for you to call in. We will field your call live and on the fly and do our best to help you and guide you, so with that I am gonna give you a little of our MyHealthQuoter.com promo. So you can get a better understanding of who we are and how we work and how you might be able to use this in the future. Again, my name is Matthew Byrne and thanks for joining us.
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This is Matthew Byrne from MyHealthQuoter.com. Thanks for joining us. Find us on Blog Talk Radio and join us next time.
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